Melbourne: October 2012
These cases are in more or less the order of examination.
Task: A 48 year old woman complains of tiredness.
Take a history, ask the examiner for investigation findings, give diagnosis, outline
The examiner was an old professor. He welcomed me warmly and asked if I understood
the task. I replied yes and he invited me to talk to the patient. I greeted the patient and
introduced myself. This is true for almost all the stations so i will not repeat this part. I
repeat all examiners were friendly and were warm.
Me: How long have you had this problem (about 2 months), any SOB, chest pain, dizziness,
palpitations, headaches, joint pains, rash, cough, diarrhoea, vomiting, abdo pain, polyuria,
polydypsia (No). Any fever (no but some night sweats), any hyperpigmentation, rash (No),
weight loss (Yes about 4 kg in 2 months), any travel history (No), periods (Normal), no
abnormal PV bleeding, no lumps or bumps, no cold or heat intolerance. No Hx of DM, HTN,
not on any medication, not taking alcohol or smoking and never used illicit drugs. Mood was
normal too. I asked as many questions to get an idea what was wrong but nothing from this
history was exciting.
Examination: General appearance was normal, Vitals T 38.5, the rest normal, no pallor,
no jaundice. No rash or a tan (haemochromatosis). CVS –normal except diastolic murmur
ICS, (then I thought IE so I asked about hand signs) no clubbing, no hand signs –
osler, janeway lesions, splinter haemorrhages. Respiratory system – NAD. Abdomen –
splenomegaly, no hepatomegaly,(here again I asked about LN enlargements elsewhere
thinking of lymphoma but the answer was negative). Rest of exam normal. I even asked
about needle marks for IV drug use but there were none.
My diagnosis was Infective endocarditis or lymphoma. Bell rang before I could mention
Blood cultures, ECHO, ECG, CXR, FBC, etc. I was gutted and for the next stations I tried hard
not to think about it.
AMC Feedback: Fever of undetermined cause: Pass.
Task: A 22 year old primigravida at 22 weeks has 2 ulcers on her vulva.
Take relevant history, ask examiner for examination findings and manage the case.
Obtained history: Normal pregnancy up to this stage, no PV bleeding, all routine bloods
were normal, No STI Hx, 5 Ps all unremarkable. Has a steady partner. Baby kicking. No
concerns at all. The ulcers were there a month before, initially painful but this time not
painful. No associated fever or PV discharge. I then asked specifically if they had started as
little blisters (No). This answer worried me now. I wasn’t sure anymore.
Examination: Normal appearance, vitals normal, abdomen HOF at umbilicus consistent with
22 weeks, nothing on abdomen, No speculum needed the vulva has 2 shallow ulcers. The
examiner said talk to your patient now.
Me: I think you have a problem called genital ulcer disease. There are 2 possibilities here
Syphillis or genital herpes simplex. Then I explained in brief that we needed to take some
bloods to investigate. Examiner then interrupted and said of the two which is the
most likely cause? Me: GHS. Examiner then asked me to assume
that was the diagnosis and manage. I said to patient: We need to monitor
pregnancy more rigorously, refer to O & G specialist as there is a concern that the child can
be affected. C/S could be an option of choice if she has herpes at term. Bell rang. Again I was
not happy with my performance here.
AMC Feedback: Vulval herpes (recurrent): Pass
Modified book case 113
Task: You are an HMO in a rural hospital 80 Km away from the nearest hospital. An 18
month old boy is brought in hospital by her mother with fever. Take a relevant history,
ask the examiner for relevant physical findings, manage the patient. On examination child
was not dehydrated, drowsy or poorly responsive as book case or cyanosed but was pale (I
missed the pallor for some strange reason hence the sepsis clue I guess). Rest of exam was
like book case.
AMC Feedback: Sepsis: Fail
An elderly lady has painful hands for several months. She feels the pain is worsening. No
need to take a history.
An elderly lady playing herself is sitting in the room. Examine her hands. Give a diagnosis.
Pleasant elderly lady sat with a pillow under her hands. I washed my hands and greeted
her warmly. I asked her if I could examine her hands to find out why they were sore. She
said ok. I started by inspection. There was no abnormalities in terms of clubbing, nicotine
satins and all those usual things we look for at general inspection. I then noted she had
some thickening of DIP joints, PIP joints and the thumbs were ?subluxed at the wrist giving a
square appearance to the hands, there was also Ulna deviation and what looked like a swan
neck deformity. There was no thenar atrophy. I asked if there was any tenderness before
palpating the joints. I felt the joints one by one from the wrist, MCPJ, PIP, DIP joints . There
was marked tenderness of the first carpo-metacarpal joint. I checked for ulna, median and
radial nerve sensory function then motor function. All briefly and normal. I then checked for
function. There was a key on the table so I checked her function and then undoing and then
doing a button on her shirt. Finally I checked for rheumatoid nodules on her elbows. There
The examiner then asked me what was the diagnosis. I said initially RA (crazy me). Then
the examiner asked me to look again at the left middle and index fingers. Here there were
both Heberdens and Bouchard’s nodes. So I said OA. The examiner then asked me whether
it was OA, RA or pt had both so I said confidently OA and bell rang. I knew I had passed this
station as if the examiner wanted me to fail he would have let me walk out with RA as the
AMC Feedback: Chronic arthritis (non rheumatoid): Pass
You are working as an intern in the ED when a young man is brought in by his friends. The
young man has been involved in a car accident at 50 Km/hr. A registrar performs a primary
survey and stabilises the patient. There are no major obvious injuries observed. You are
asked to see the patient now. Perform a focused physical examination. Answer examiner’s
The patient was a young man wearing a hard neck collar sitting in a chair. I washed my
hands and asked the patient how he was feeling then asked if I could examine his face. I
started by general exam of the face. I could see a bruise on the below the left eye. I checked
ENT for any discharge. There was none. I then checked visual acuity (roughly as there was
no snellen chart) which was normal. Pupils were equal, round and reactive to light (about 5
mm). Fundoscopy was normal upon enquiry. Peripheral vision was normal. On checking eye
movements pt had diplopia on looking up and outwards on the left side. Facial sensation,
nerve, was fine but the strength of chewing was reduced on the left (temporalis and
masseter muscles). 7th
nerve palsies secondary to orbital floor fracture. I said I will send pt for CT spine and
head/face. The examiner wanted to know whether it was an infra or superior orbital floor
fracture. I said I was not sure but maybe superior. He said that’s ok if you are not sure and
AMC Feedback: Examination of face following facial trauma: Pass
nerve was intact. At this point I stopped my exam and said pt had 3rd
A young nurse has come to get a sick certificate. She was diagnosed with OCD a week ago.
Get any further relevant history and manage the patient.
I walked into a room where patient was sitting wearing non sterile gloves. After
introductions, I assured pt of confidentiality and proceeded to get a brief history. Pt was
staying with husband who was very supportive. They had a 3 year old daughter. No FHx
of psychiatry, no head injury, no SAD, no suicide ideation. Agreed that she had a problem
that was bothering her, excessive washing of hands fearing infections, repeating this ritual
bothered her and she knew it was not normal and wanted a stop to this. She had no other
compulsions, no phobias. There was nothing interesting in HEADDS.
I explained what OCD was and she understood. I said treatment would include CBT with
referral to psychiatrist who will try exposure response prevention methods. Usually this
works but in case it did not work out there were medicines to be given. Said I did not want
to talk about that in this consultation as I was confident all would work out because pt was
motivated to change. Family meeting with husband would be organised and some reading
material given. Pt was happy with plan but wanted sick certificate which I said was a good
idea. There were no further questions and left the room just before bell rang.
AMC Feedback: Obsessive –Compulsive Disorder: Pass
A 30 year old lady with schizophrenia is brought in by her husband. She was recently
diagnosed with breast cancer but in its early stages. She has stopped coming for her follow
up with her surgeon as she does not believe she has no cancer. Take any further relevant
history. Give a mental state report. Assess risk and how you would proceed.
After the introductions, I assured pt of the confidentiality of the nature of our interview.
Pt said she was not taking her medication because she did not believe she had cancer and
she was sure her neighbours were plotting against her. She was hearing voices being rude
to her and warning her of her neighbours. In summary I learnt that pt had not been taking
her medication for about 1 month, she had no suicide ideation, mood was not depressed,
she lived with her husband and he had brought pt to hospital, she kept saying she did not
want to be here, she had no concerns, had no sleep disturbance, no change in appetite
but had gained weight, had no insight, HEADDSS questions – nothing exciting. No visual
hallucinations, no delusions of grandeur, thought insertion, thought withdrawal, ideas of
reference, thoughts broadcast were all present.
Mental state report. Appearance – well dressed, but looking around all the time, poor eye
contact. Behaviour – looking around uneasy and suspicious. Mood – sad, affect - congruent
with mood, perceptions – no delusions but some auditory hallucinations, Speech –
monotonous, not pressured, Formal thought – normal, no flight of ideas. Poor insight,
oriented in time place and person, judgement was poor too.
I assessed pt as a high risk to commit suicide or homicide (hearing voices that could
easily push her to the above). I stated that pt had a relapse of schizophrenia due to
non compliance. I therefore proposed immediate admission under psychiatrist and
commencement of antipsychotics.
AMC Feedback: Treatment refusal: Pass
A 5 year old boy is brought in by his father with a palpable lump in his cervical region. His
cousin was diagnosed with lymphoma a few months earlier. The father is worried his child
might be having the same condition. Take a relevant history from father, ask for relevant
physical findings and advise the parent.
I met the father who was initially worried because a cousin had lymphoma. The obtained
history was that the child had had a cough and signs and symptoms of URTI a month earlier
which resolved on pain relief over a few days. However, parent noted a swelling in the neck
and got worried. Father noted that the swelling had become less pronounced over the last
few days. Currently child was fine, playing, eating well and gaining weight , no fever, cough,
rash or any concerns. BINDS – all normal. Examination: Vitals normal, normal growth charts,
ENT, head and neck all normal save for cervical LN 1 cm in left side, non tender, smooth,
non nodular. No LN anywhere else. Rest of exam was normal. I assured the parent that
this was an innocent LN that occurs after an infection in the head and neck region and will
resolve with time. Reassured pt that as the child was well and thriving there was no need for
alarm. I also said I understood you are worried about lymphoma but this is highly unlikely
but to put your mind at ease we can do FNAC which will confirm what I have just said. You
can come back after a week or so for review so we can monitor the size of the LN. Father
was happy and I left the room early.
AMC Feedback: Lymphadenopathy: Pass
You are a new GP in town. Your next patient is a young mother who presents at 37 weeks
gestation for a check up. You have not seen this patient before. She has forgotten her
antenatal card with all her information. Take a relevant history and manage her.
A pregnant woman probably at 37 weeks was sitting there tense when I walked in. I asked
about current pregnancy, she was a primi, any bleeding, pain, discharge, contractions,
swelling of limbs, fits, booking bloods, U/S scans early and late, screening tests (downs was
done), BP checks and sweet test. All were normal. 5 P were non contributory. Then she said
my only concern is that the baby has been moving less since this morning. I asked about
any fever or trauma, again negative. Exam; Vitals all normal, no oedema, then focusing on
the abdomen; HOF 37 cm, cephalic presentation, longitudinal lie, head not engaged, no
contractions, FH not heard. No speculum or vaginal exam required. I then explained to
the land sympathetically that if she liked I would like her husband to come in and hear the
diagnosis, pt said she would be fine then I told her there is some concern here as we cannot
hear fetal heart. Patient need to go to hospital for CTG and possibly an ultra sound to see
what is going on. There is a danger that the child might have demised in utero. The reason
would be difficult to know at this point but if indeed the child had died an autopsy would
be required. Options available would be induction of labour or waiting for labour to occur
naturally. The woman would need to make that decision. I was sympathetic. The woman
was ok with the plan. Examiner asked me what other possibilities for us failing to hear fetal
heart. I said body habitus of mother, ie obesity. He concurred and bell rang.
AMC Feedback: Decreased fetal movements at 37 weeks: Pass
A 22 year old female who has never been pregnant before presents for her result. She
has been having PAP smears since the age of 16 and they have all been normal until the
latest one which shows CIN III. Take a relevant focused history and advise the patient on
immediate and long term complications.
Patient was a young woman who said she was sexually active or OCP since 20, regular
menses, no abnormal bleeding, no history of multiple partners, no Hx of STI, no SAD.
Essentially the history was short and very focused. I then went on to describe what CIN 111
was in relation to Ca cervix. I assured pt that she did not have cancer but she had abnormal
cells which herald Ca cervix and these changes may develop over 5 to 10 years but at the
moment the abnormal cells were of a higher degree of abnormality as opposed to low
grade. Hence pt needed referral to O&G specialist who will arrange colposcopy, which is low
power magnification of the cervix by a microscope followed by removal of the area of cervix
with abnormal cells after taking up some dye. I drew a diagram of the uterus and cervix as I
described cone biopsy. I warned pt of immediate complications, bleeding, infection and long
term complications like stenosis or cervical incompetence. I explained a little more about
painless delivery as incompetence but reassured that there were ways available to deal with
this. Finally I advised pt of the need to continue yearly PAP smears even after cone biopsy.
Pt had no questions. I offered reading material.
AMC Feedback: High grade cervical lesion on Pap smear: Pass
A young boy (maybe 13) has had his spleen removed (reason probably traumatic). Talk to
the father about immediate and long term complications and how you will manage them.
After the formalities of greetings including I wish you a speedy recovery, I went on to say
that there were three important things I need to discuss with you. I explained the function
of the spleen in filtering the blood and removing bugs. The first is immediate complications
which include infection (wound, chest, UTI), haematoma or bleeding, DVT (or PE). After
this there is long term complications like recurrent infections, chest especially. The last
part is about preventing these potential recurrent infections (from encapsulated bacteria).
Therefore we need to immunise your child against bugs causing pneumonia, meningitis. The
3 vaccines will be meningococcus, Pneumovac and Haemophilus influenza type b. This will
be on top of the other regular vaccinations. Any sign of infection will need to be handled
quickly by reporting to your GP as soon as possible. Furthermore, before any minor or major
procedure patient will need prophylactic antibiotics as well. Finished on time.
AMC Feedback: Complications after splenectomy: Pass
A 30 year old female was diagnosed with hypertension a few months ago. She has had
some tests which show normal renal function, normal cholesterol and blood glucose. She
has been investigated for secondary hypertension but the cause was not found. Talk to the
patient to ascertain why she is not compliant with her treatment.
The role player was a young lady. She was not concerned at all about the consequences
of not taking medication at all. She said she had taken medication for a few months then
when they ran out she did not see the need. She did not have any symptoms at all of
uncontrolled hypertension (headaches, dizziness, palpitations, etc). FHx – father had a
stroke in his 60s, mother was hypertensive but had no problems. I asked if mother was
taking medication, she said yes then I said it was probably because she was compliant (both
examiner and patient smiled). I asked about other possible co-morbidities like Diabetes,
hyperthyroidism, etc, I asked about smoking, drinking, other drugs, any other current
medications. All negative. Then I outlined the complications of uncontrolled hypertension:
stroke, cardiomyopathy, heart failure, renal impairment, heart attacks, visual problems,
peripheral vascular disease. I explained each one of these is simple laymen terms. In the end
I asked if she had any questions. She had none. I then advised her to take her medication,
come for regular follow up, have repeat blood tests for kidney function, cholesterol, blood
sugar, and urinalysis in the near future. I gave her reading material and wished her good
AMC Feedback: Non-compliance with anti-hypertensives: Pass
You are a GP working in town. A 40 year old builder has come back for his results. Last
week he had a surgical consult for a long standing mole that had become itchy recently.
A biopsy confirmed a Clark level 0.4mm deep malignant melanoma. Talk to the patient. I
concentrated on breaking the bad news, referring pt to surgeon for wide skin excision (at
least 1cm margin), outlined other investigations to rule out metastatic spread. I spoke about
good prognosis as depth was less than 0.75mm, organised follow up, reading material,
regular checks for recurrence, excessive sun exposure avoidance measures. I did not have
much to say and left room early.
AMC Feedback: Melanoma: Pass
A 3 year old child had sudden onset swelling of lips, tongue, eyes and a generalised skin rash
after exposure to peanut butter. She recovered completely in the next 3 hours. You are an
HMO working in a hospital when a parent brings her 3 year old daughter to see the allergist.
However, the allergist is called for an emergency and the patient is brought to you. Talk to
the mother and answer her questions.
I young woman smartly dressed was sitting looking a bit worried. I first reassured her that
peanut and egg allergies were common in children and in most cases are well managed
mostly with simple medication and only in rare cases do we get bad outcomes. I enquired
about the episode. The child had recovered within 3 hours and had been discharged. I
advised parent to get an epipen, a bracelet written peanut and egg allergy, not for child
to share food at school, to inform the teachers, parents of friends if child goes on play
dates, to keep some antihistamines the house for minor allergic reaction, to watch out for
problems with breathing (airway, breathing and circulation in simple terms) and finally
to book another appointment with the allergist. Parent then asked if child could receive
immunisations as some contain egg. I said off the top of head I could not tell which vaccines
contain egg but I would check for her and also said there could be substitutes in some cases.
AMC Feedback: Egg and peanut allergy: Pass
A young lady has come for review after complaining of left calf pain and swelling. The report
of the Doppler shows that she has a DVT. Take a focused history and manage patient. GP
This case was about getting a short relevant history in about 3 minutes only. I asked about
any trauma to the leg, recent surgery, long distance travel, any medication including OCP
(yes to OCP), Family history of blood clots, any previous blood clots, No alcohol, smoking
Hx, No Hx of malignancy, liver disease. No chronic illness.
I began by explaining the meaning of DVT in simple terms. The patient understood my
explanation then I told her we need to send her to hospital for admission, start her clexane
then followed after 12 hours with warfarin. I explained the reason for this treatment, blood
thinning to prevent clot extension. I also explained the monitoring with INR checks, which
I discussed in detail. I mentioned that we would like to take blood for a thrombophilia
screen which I explained as a measure of the propensity for blood to clot. I advised pt to
stop OCP and use other methods of contraception. I also said in future never to use OCP
and always mention this to Dr. To watch out for sudden severe chest pain or SOB (PE),
bruising, haematuria, bleeding (warfarin toxicity). Never to miss medication even when sick.
To inform Drs when prescribed other medication that you are taking warfarin and finally
treatment would be between 3 and 6 months.
AMC Feedback: Spontaneous DVT: Pass
Modified book case 112
A 40 year old man presents with diarrhoea. He has come to see you in your GP practice.
Take a further history and manage the patient. Patient had both blood and mucous in his
stool. DRE revealed blood on gloved finger. Therefore, i spoke about both UC and Crohns
with a diagram to aid understanding
AMC Feedback: Inflammatory bowel disease/ulcerative colitis: Pass
I would like to thank Dr Wenzel for all he has done and continues to do for IMGs. His
influence is legend. Family, friends, study partners and colleagues also played an important
part in my preparation. It s a tricky exam but with composure and confidence it is very
possible. If you get an opportunity please go for some trial exams. They are really helpful. I
wish you all the best.